Easing winter pressure by keeping the elderly out of hospital

Published: 16th July 2018

Last month, The Royal College of Emergency Medicine published its Winter Flow Report for 2017/18. Its President, Dr Tajek Hassan, commented: “This report bears out what we’ve seen elsewhere and reflects what our members have been telling us: this was the worst winter we’ve ever experienced.“ It comes as no surprise after what we knew already […]

Last month, The Royal College of Emergency Medicine published its Winter Flow Report for 2017/18. Its President, Dr Tajek Hassan, commented: “This report bears out what we’ve seen elsewhere and reflects what our members have been telling us: this was the worst winter we’ve ever experienced.“

It comes as no surprise after what we knew already from a January Telegraph article that reported that more than 20 hospitals had declared a black alert. Part of the problem is not being able to discharge elderly patients if there is insufficient social care support. But discharge is not the only problem. According to some of the consultants in Hospital Trusts we work with, there is also the issue of whether elderly patients should be admitted at all in certain circumstances. Hospital admissions are full of risk; infection, falls, deconditioning are all common in hospital.

Feedback suggests that giving GPs access to Advice & Guidance from a consultant can be an admittance-saver, and in case of the elderly, could even be a life-saver.

Here’s a case from Dr Lorna Burn, a GP in North East Essex:

“An elderly patient with heart failure complicated by a valve prolapse was under my care. Her management was delicate as she has co-existing renal failure that meant it was difficult to balance her diuretics and manage her polypharmacy. I was able to contact her cardiologist via Telephone Advice & Guidance (A&G) and get advice one day when she was unwell. I was able to establish what an acceptable renal function for her would be with the new diuretic regime, and also second and third line drugs to try next. I was able to avoid admitting the patient and she remained in her own home whilst I adjusted her medication, which is what she wanted. Having a clear plan gave her reassurance and me confidence to manage her when she was more unwell.”

Dr Jo Russell, GP in Solihull, shares her experience: “Referral of frail, elderly patients to hospital is almost always complicated because of their co-morbidities and is sometimes not in the best interests of the patients. Telephone A&G gives me immediate access to a senior specialist colleague and an immediate outcome and plan. This is of huge benefit to these patients.”

An as another clinician puts it, there are also problems with elderly patients being admitted when better pathways exist: “For example, we see very anaemic patients who are in need of a transfusion. We have a day unit for this that the patient can attend, without being admitted, and it is better for both the patient and the NHS. But many people who deal with the frail elderly, such as care home staff, don’t know about this.”

“If you aren’t a clinician and you aren’t confident in deciding on a course of action, calling 999 may seem like the best option for the patient. What happens then, though, is that, instead of a trip to a day unit, an ambulance is called, the patient is assessed in the EAU from where they will likely go on to stay in a ward. There are often many alternative options available, including domiciliary visits by myself or my colleagues if necessary.”

Our own data from Consultant Connect projects supports the idea that elderly patient admissions can be avoided – 18% of Advice & Guidance calls from GPs to specialist Elderly Care consultants result in the patient avoiding an admission (a further 37% of calls avoid an unnecessary elective referral).

An Elderly Care Consultant told us: “In most cases it is the simple sharing of information about a patient that is key. The person we speak with might be the manager of a care home, a community nurse, a GP or a paramedic. As long as we can get the information we need, we can help make a decision that will hopefully result in the best possible outcome for the patient. On the phone, you can ask focused questions which might not be the same if you were putting it in an email.”

Read some of our cases studies about how access to Advice & Guidance has resulted in better patient experience for the elderly as well as reassurance for GPs:

To arrange a call to discuss how a telephone Advice & Guidance service might work for GPs and other workers dealing with the frail elderly in your area, please call us on 01865 261467 or email us at info@consultantconnect.org.uk